Provider Demographics
NPI:1194772434
Name:KAVANAGH, GRAHAM GEORGE (PHD)
Entity type:Individual
Prefix:DR
First Name:GRAHAM
Middle Name:GEORGE
Last Name:KAVANAGH
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 W 56TH ST
Mailing Address - Street 2:35A
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10019-4312
Mailing Address - Country:US
Mailing Address - Phone:212-247-1831
Mailing Address - Fax:212-247-0255
Practice Address - Street 1:211 W 56TH ST
Practice Address - Street 2:35A
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10019-4312
Practice Address - Country:US
Practice Address - Phone:212-247-1831
Practice Address - Fax:212-247-0255
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-30
Last Update Date:2014-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008331103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYV41401Medicare ID - Type UnspecifiedPSYCHOLOGIST